Contact person in case of emergency:
Extended Breast Questionnaire
Diagnosed with breast cancer:
Breast biopsies or surgery:
"Please choose the area closest to the biopsy or surgery location. The exact location will be discussed and marked at your appointment. Extra scans will also be taken with a pointer to show the exact location for the doctor to review."
Diagnosed with other breast disease:
General Medical History: Past and Current medical problems (please include dates)
Family History: Please indicate the current status of your immediate family members
(Mother, Father, Sibling, Grandparent, Aunt, Uncle)
I understand that the Report generated from my images is intended for use by trained health care providers to assist in evaluation, diagnosis and treatment. I further understand that the Report is not intended to be used by individuals for self evaluation or self-diagnosis. I understand that the Report will not tell me whether I have any illness, disease, or other condition, but will be an analysis of the Images with respect only to the Thermographic findings of the areas discussed in the Report.
This document is confidential and legally privileged. Any retention, dissemination, distribution or copying of this
communication is strictly prohibited. All information is correct to my knowledge
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Midnight Sun Healing is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Disclosure of Your Health Care Information
We may disclose your health care information to other healthcare professionals within our practice or associated with our practice for the purpose of treatment, payment or healthcare
"On occasion, it may be necessary to seek consultation regarding your condition from other health care providers within or associated with Midnight Sun Healing for the benefit of providing you with more health care information.
We email a receipt to you that can be sent to your insurance provider for the purpose of payment or health care operations.
"As a courtesy to our patients, we email an itemized receipt for you to submit to your insurance carrier for the purpose of showing payment to Midnight Sun Healing for health care services rendered. The receipt contains our business information, your name and address, type of scan, price of scan, form of payment and date of service. If more information is needed please call our office at 920.660.3320 and we will be
happy to assist you.
We may disclose your health information as necessary to comply with State Workers' Compensation Laws.
We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings.
We may disclose your health information in the course of any administrative or judicial
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
We may disclose your health information to coroners or medical examiners.
We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public
Specialized Government Agencies.
We may disclose your health information for military, national security, prisoner and government benefits purposes.
Change of Ownership.
In the event that Midnight Sun Healing is sold or merged with another organization, your health information/record will become the property of the new owner.
Your Health Information Rights
Changes to this Notice of Privacy Practices
Midnight Sun Healing reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Midnight Sun Healing is required by law to comply with this Notice.
Midnight Sun Healing is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Jacque Kress by calling this office at 920.660.3320. If Jacque Kress is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
Complaints about your Privacy Rights or how Midnight Sun Healing has handled your health information should be directed to Jacque Kress by calling this office at 920.660.3320. If Jacque Kress is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
This notice is effective as of 01/01/2014.
I have read the Privacy Notice and understand my rights contained in the notice.